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Oklahoma Society ofHealth System Pharmacists2017 Residency Research ConferenceMay 19, 2017Oklahoma City, OKORIGINAL RESEARCHThese abstracts describe original research submitted for presentation. Categories include clinical practice, diabetes care, hematology/oncology, infectious diseases, and pediatrics. Clinical Practice 1. UTILIZATION OF LOCKBOXES FOR CONTROLLED MEDICATIONS TO REDUCE DRUG DIVERSION AND PREVENT ACCIDENTAL OVERDOSE. Giau Phan, Polly Robinson, Stephanie Tillman. St. John Medical Center, Tulsa, OK INTRODUCTION: Prescription drug abuse is a serious public health issue that affects every community. The most commonly abused medications are opioids and benzodiazepines. In Oklahoma, between 2007 and 2011, there were 2,535 death related to prescription drugs. Tulsa is ranked 18th out of all counties in the US for painkiller deaths. More than 68 percent of people age 12 and older obtain drugs from friends or relatives. This project is designed to assess the benefit of lockboxes in reducing Tulsa’s prescription drug abuse problem. The goals are to reduce the potential for diversion and prevent accidental overdose by unauthorized users. METHODS: The study is pending approval by the Quality and Safety Executive Committee as a quality improvement project. Patients, who are 18 years or older and discharged with prescriptions for controlled medications, will be prospectively selected from September 2016 to February 2016. Participants will be surveyed and provided a lockbox for home use along with written and verbal counseling on proper storage and disposal of medications. Follow up via telephone will be scheduled at 3 months to determine the benefit of the lockboxes as well as any behavioral changes in disposal of medications. All data will be recorded without patient identifiers to maintain confidentiality. RESULTS: Results from this study will be used to assess the benefits of lockboxes regarding safe storage of controlled medications in the outpatient setting. It is expected that with increased utilization of these lockboxes, they will help reduce drug diversion and prevent accidental overdose. 2. FOUR-FACTOR PROTHROMBIN COMPLEX CONCENTRATE OUTCOME MEASURES IN PATIENTS RECEIVING WEIGHT-BASED DOSING VERSUS FIXED-DOSING IN A HOSPITAL SETTING WITH ESTABLISHED GUIDELINES FOR USE. John Jacob Cannedy, Julia Chiappe. INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma INTRODUCTION: Four-Factor prothrombin complex concentrate (4FPCC) is labeled for urgent reversal of acquired coagulation factor deficiency, induced by vitamin-K antagonists, and off-label for oral anti-Xa inhibitors. The health-system’s formulary committee instituted a fixed-dosing protocol for 4FPCC dosing adapted from recent literature. The purpose of this study was to evaluate the clinical effectiveness, safety, cost effectiveness, and degree of prescriber compliance with the newly established 4FPCC fixed-dosing protocol, within the affiliated health-system, by comparing patients and outcomes before and after its implementation.METHODOLOGY: This study included adult patients within the affiliated health system who received only 4FPCC for urgent reversal of warfarin or an oral anti-Xa inhibitor before and after implementation of the fixed-dosing protocol between June 1, 2013 to May 19, 2016 and May 20, 2016 to October 3, 2016 respectively. Data for population comparison included: patient demographics, agents and indications for chronic oral anticoagulation, presence of other prescription or inpatient medications affecting hemostasis, laboratory values and blood component use before and after 4FPCC administration. Additional data collected to derive the measures for evaluation of fixed-dosing protocol included: number of 4FPCC doses to reach international normalized ratio (INR) less than two for warfarin reversal, cumulative 4FPCC units administered, rates of thrombotic complications within seven days from 4FPCC administration, patient mortality, and patient discharge disposition.RESULTS: Preliminary analysis of 52 patients indicated that 42 patients received weight-based dosing of 4FPCC compared to 10 patients in the fixed-dosing group. Warfarin reversal results indicated that the average dose of 4FPCC used in the weight-based dosing category was 31.4 units/kg and 23.6 units/kg in the fixed-dosing category. Results also indicated that the reduction in INR after the first dose of 4FPCC was on average 2.84 in the fixed-dosing group and 3.39 for the weight-based dosing group. The average time to first post-dose follow-up was 21 hours in the fixed-dosing group and 4.8 hours in the weight-based dosing group. Within the warfarin reversal population, fixed-dosing required no blood product administration after 4FPCC use. The results from the Factor Xa reversal population indicated that the average dose within the weight-based dosing group was 40 units/kg compared to 23 units/kg in the fixed-dosing group. The fixed-dosing group, on average, had less blood product administration compared to weight-based dosing. Fixed-dosing for both warfarin and Factor Xa reversal preliminarily showed longer lengths of stay compared to the weight-based dosing group. Thrombotic complications occurred in 4% of the weight-based dosing patients compared to no complications in the fixed-dosing population. CONCLUSIONS: Based on the preliminary data, annual product cost savings for the hospital could be greater than $50,000. There is also opportunity for appropriate follow-up with fixed-dosing protocol utilization, decreased waste, and faster administration time. 3. IMPLEMENTATION OF A PHARMACY-DRIVEN METABOLIC VALIDATION TESTING IN A NATIVE AMERICAN POPULATION. Jamie Wroge, Stacy Gee, Travis Freeze, Carrie Law, Steven Fillmore. Chickasaw Nation Medical Center, Ada, OK. PURPOSE: The use of metabolic validation with genetic testing is the first step towards personalized healthcare. The objective of this study is to determine how metabolic validation in a Native American population at the Chickasaw Nation Medical Center can help improve patient care by tailoring drug therapy to the patient which may help to decrease adverse events, improve targeted therapies and dosing, and help choose a more efficient, cost-effective medication. METHODS: The electronic medical record system will be used to identify patients who qualify for laboratory testing criteria for metabolic validation testing with one or more of 3 panels including neurology, cardiology, and/or thrombophilia. Pharmacists will screen patient and perform the cheek swab. The test is sent for analysis. Imperative results are sent to the provider immediately and all results are scanned into the electronic health record note template for the health care team to review.RESULTS: A preliminary analysis of 75 patients with metabolic validation was performed. Of those patients who were tested 81.3% were poor metabolizers of CYP 3A5, while intermediate metabolizers of CYP 3A5 accounts for 17.3% of the patients. Ultra-rapid metabolizers of CYP 1A2 make up 65.3% of patients. CONCLUSION: Efforts are progressing towards having specific pharmacogenomics information about Native American population. More data needs to be collected before a wide spread conclusion can be made about how the Native American population might respond to medications.4. IMPACT OF PHARMACIST-DELIVERED PATIENT EDUCATION ON ADHERENCE TO DUAL ANTIPLATELET THERAPY FOLLOWING ELECTIVE PERCUTANEOUS CORONARY INTERVENTION OR ACUTE CORONARY SYNDROMES. Authors: John Dechand, Alexander Schneider, Stephen Neely, Toni L. Ripley. University of Oklahoma Health Sciences Center College of Pharmacy Oklahoma City, OKINTRODUCTION: Adherence with secondary prevention medications after an acute coronary event declines most significantly in the first month after discharge. This non-adherence is associated with an increased risk of death at 12 months and is most substantial with dual antiplatelet therapy (DAPT). We implemented a pilot quality improvement (QI) project as a discrete transitions of care intervention that focused on DAPT education.METHODOLOGY: This is an analysis of a QI project to evaluate structured DAPT education from a clinical pharmacist (CP). Patients who received discharge education on DAPT from a CP between 9-1-2016 and 12-15-2016 will be compared to those patients who did not receive education from a CP. The primary endpoint is adherence to DAPT at 30 days, measured via the proportion of days covered (PDC) calculation. Secondary endpoints include 30 day readmission and comparison of patient-reported adherence with pharmacy refill data. Statistical analysis using the appropriate tests for categorical variables will be used to compare case and control status. This study has been submitted for Institutional Review Board approval.RESULTS: Sixty-five patients received structured DAPT education during the specified timeframe. Of these 65 patients, 40 that met our inclusion criteria had pharmacy refill data and patient recall data available from the QI project, and therefore serve as out intervention cohort. For the primary endpoint, all patients were defined as adherent (PDC ≥80%), and 93% of patients were fully adherent (PDC = 100%). All but one patient filled DAPT on the day of discharge. Comparison to the control group is in progress.CONCLUSION: The results will be discussed.5. BRIDGING THE VACCINATION KNOWLEDGE GAP WITH AN EDUCATIONAL GAME TO INCREASE ADMINISTRATION RATES IN ADULTS, 50 YEARS AND OLDER. Kristi D. Rice, Nancy T. Williams, Henry W. Kinnard. Southwestern Oklahoma State University/Walgreen Co., Oklahoma City, OK.PURPOSE: In the last few years, the United States has faced outbreaks of whooping cough in our infant population, increased occurrences of hospitalizations from shingles, and rising numbers of deaths from Streptococcus pneumoniae. Many people realize that vaccines are important for children; however, barriers inhibit adults from receiving their vaccinations. Objectives: 1) identify baseline knowledge and willingness to be vaccinated with tetanus, diphtheria, acellular pertussis (Tdap), pneumococcal 13-valent conjugate (PCV13), pneumococcal 23-valent polysaccharide (PPSV23), and herpes zoster (HZV) vaccines; 2) analyze feedback on an educational game as a teaching tool; and 3) compare vaccination rate data to prior year, in adults 50+ years.METHODS: Approximately 50-75 adults 50+ years will be recruited while visiting the community pharmacy. A secondary community pharmacy site nearby will be selected, if recruitment is low at the primary site. This study will follow the Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices guidelines. Patients who meet the study age requirement, with no exclusion criteria, will be asked to sign an informed consent statement and participate in pre-educational session surveys assessing demographics, baseline knowledge, and willingness to receive vaccines. The educational session, lasting 15-30 minutes, involves a laptop-based, Jeopardy-style learning game. The session covering Tdap, PCV13, PPSV23, and HZV will teach patients about these vaccine-preventable disease states, importance of adult vaccines, and herd immunity. Next, patients will be given a post-educational survey and administered any vaccines if interested. Participants with unknown vaccine history will be asked for permission to contact their physician and thus may need to return at a later date to receive vaccines. The University IRB Committee and Walgreens Corporate have approved this study, which will last for a four-month period (12/2016-3/2017), with loyalty rewards points offered. The data will be analyzed with descriptive and quantitative statistics.RESULTS: As of late March 2017, 54 patients had participated. The population was mostly Caucasian (67%), female (57%), average age of 60, and average education level of some college (44%). Only 9 had a healthcare degree, and 98% had insurance. Over half (70%) responded “yes” to their healthcare provider discussing vaccines with them, and 67% answered “yes” they are current on their adult vaccines; however, several answered “no” or “I do not know” when asked if they received their Tdap (28%), PCV13 (78%), PPSV23 (81%), or HZV (85%) vaccines. While 22% were willing to receive a vaccine following the session, only five patients (9%) actually received vaccines. Average vaccine knowledge survey scores went up 18% following the educational session. Most patients either strongly agreed or agreed (98%) that the session helped them understand vaccines, and 67% answered their adult vaccines are now a high priority. Unfortunately, store data for the targeted vaccines indicated a 41% decrease in administration rates from last year. Data collection will continue through March 2017.CONCLUSIONS: Pending conclusion of data collection.6. EVALUATION OF THE CONVERSION FROM MEDICATION CHARGE ON DISPENSING TO CHARGE ON ADMINISTRATION IN A COMMUNITY HOSPITAL. Robert L. Holliday, Jenny Stemm, Darin Smith, Norman Regional Health System, Norman, OK.PURPOSE: Norman Regional Health System is a three-hospital non-profit community health system that utilizes an electronic medication administration record for documenting medication administration through a bar-coded medication system. The pharmacy department currently generates a patient medication charge upon dispensing the medication, either directly from the pharmacy or from a dispensing cabinet. Discrepant billing practices may occur for several reasons including: 1) Medications not returned to the pharmacy for credit before processing the bill; 2) medication is lost or dropped on the floor requiring an additional dose that is inadvertently charged; 3) lack of administration documentation. By changing to a charge on medication administration process, the heath system will ensure greater accuracy in billing. The health system will benefit from prevention of potential loss of Medicare reimbursements due to billing errors identified during an audit.METHODS: A complete list was made of all the areas where medications are dispensed and charged. This included the Pyxis machines, crash carts, totes and trays, outpatient infusion, and the dialysis unit. The areas were selected and audited against a patient’s bill to check for accuracy. A baseline was established based on the number of discrepancies. From the audits, it will be determined whether it will be appropriate for that area to be switched to a charge on administration status. Upon completion, pharmacy will work with Health Information Technology to implement the conversion to charge on administration. After implementation, a follow up audit will be completed to evaluate for improvements and accuracy in billing practices. Pre- and post-implementation pharmaceutical revenue will also be evaluated. RESULTS: Preliminary data show that the most common billing discrepancies occur with saline flushes, intravenous fluids, and medications administered in surgery or catheterization lab. Medications that are administered during surgery are documented in an anesthesia record rather than on the electronic medication administration record.CONCLUSION: Based on preliminary data, switching certain areas within the health system to charge on administration may lead to improved billing practices. Areas that document on a paper record, such as surgery or catheterization lab, may need to be delayed in the switch to charge on medication administration until a solution for charting on the electronic medication administration record can be found. 7. THE STANDARDIZATION OF ADMISSION AND SPECIALTY ORDER SETS TO MINIMIZE DUPLICATE MEDICATION ORDERS. Victoria N. Felder, Jerri Cody, Debbie Poland. Norman Regional Health System, Norman, OK. PURPOSE: To quantify the frequency of duplicate orders, identify medications frequently associated with duplicate orders, and analyze the impact of current physician practices utilizing order sets containing as needed medication orders.METHODS: Using data retrospectively collected from the institutions electronic records, patients with more than one order for acetaminophen in a one week time period were assessed for number and type of order set used.RESULTS: 841 orders for a total of 480 patients were analyzed; ultimately 69 patients were found to have two or more order sets that were ordered with duplicate acetaminophen orders, totaling 172 order sets. These were sorted into the following categories: the same physician ordering the same order set (9), the same physician ordering different order sets (39), different physicians ordering the same order set (15), and different physicians ordering different order sets (36). Patients with more than two order sets (23 patients), could fall into more than one category. CONCLUSION: The duplication of medication orders via various order sets occurs frequently, with 107 excessive order sets ordered in a one week time period. This has the potential to lead to duplicate orders on the patient’s profile, potentially leading to medication errors such as multiple administration of the same medication. These excessive order sets also require additional pharmacist time to verify and ensure that patients do not have medications duplicated, which could be utilized elsewhere in the pharmacy.Diabetes Care 8. IMPACT OF A PHARMACIST-MANAGED DIABETES CLINIC ON PATIENTS WITH POORLY CONTROLLED DIABETES. Kate Lutek, Todd Marcy, Lauren Snodgrass, Susan Rourke-Webb. Oklahoma City VA Health Care System, Oklahoma City, OklahomaINTRODUCTION: Type 2 diabetes poses a significant threat to the health of the United States, affecting approximately 29.1 million Americans. Complications of diabetes occur at higher rates with increasing glycemia and can include blindness, amputation, and end-stage renal disease. Many patients in the United States have poorly controlled diabetes. Clinical pharmacists are well-trained and well-positioned to address barriers in achieving glycemic control. The purpose of this study is to determine the effectiveness of pharmacists in the management of patients with poorly controlled diabetes and to determine the patient-satisfaction of an outpatient pharmacist-managed diabetes service.METHODOLOGY: This study will include retrospective evaluation of improvement in glycemic control and a patient satisfaction survey of the pharmacist-managed diabetes service. It will be submitted for approval by the University of Oklahoma Health Sciences Center Investigational Review Board. Patients will be identified from the diabetes pharmacotherapy service within the Oklahoma City Veterans Affairs Health Care System (OK VAHCS). To be included in the study, patients must have a hemoglobin A1c (A1c) value of 9.0 percent or greater in the six months prior to their first clinic appointment, as well as an A1c value taken after at least one clinic appointment and within the three to six months following clinic enrollment. Patients with a diagnosis of type I diabetes mellitus will be excluded. Patient encounters between July 1st, 2015 and December 31st, 2016 will be retrospectively reviewed. Absolute change in A1c and achievement of an A1c less than 9.0 percent and less than 7.0 percent will be measured to determine the improvement in A1c following enrollment in a pharmacist-managed diabetes pharmacotherapy clinic. Data will also be collected to evaluate predictors of successful A1c lowering as a secondary endpoint. Baseline demographics will be collected. In addition, patients enrolled in the diabetes service will be offered the opportunity to participate in a telephone-conducted patient satisfaction survey.?RESULTS AND CONCLUSION: Results are pending evaluation of data, and will be presented at the conference.9. CLINICAL IMPLICATIONS AND PRESCRIBER ATTITUDES REGARDING NEW FDA RECOMMENDATIONS WITH METFORMIN PRESCRIBING. Elizabeth A. Cook, Katherine S. O’Neal, Michael J. Miller, Ann E. Lloyd, Laura J. Chalmers. University of Oklahoma College of Pharmacy - Tulsa Campus, Tulsa, OKINTRODUCTION: Metformin is a renally eliminated drug endorsed by the American Diabetes Association as first-line therapy for treatment of type 2 diabetes (T2DM) because of its efficacy, safety, and mortality outcomes. The U.S. Food and Drug Administration (FDA) revised prescribing recommendations, requiring labeling changes to reflect dosing according to estimated glomerular filtration rate (eGFR) rather than serum creatinine. This revision expands eligibility to those with mild to moderate renal impairment. The purpose of this study is to identify potential gaps in prescribing practices following this revision, as well as assess knowledge and attitudes of providers concerning the renal adjustment of metformin.METHODOLOGY: This is an IRB approved retrospective chart review coupled with an anonymous survey. An electronic medical record system will be used to identify patients, seen by providers at an academic outpatient clinic in Tulsa, Oklahoma from January 1, 2015 to December 31, 2015. Patients eligible for review must have a diagnosis of T2DM. The following data will be collected: date of birth, sex, ethnicity, serum creatinine, eGFR, and the date that these laboratory values were measured. The dates of outpatient appointments, prior to and following receipt of laboratory results, as well as the total daily dose of metformin, prior to and following lab results, will also be collected. Data will be used to calculate the change in patient eligibility for metformin therapy within the provider network based on newly issued guidelines concerning dose adjustment based on eGFR. Additionally, a survey will be distributed to physicians and advanced practice providers. Non-identifiable demographic information for each provider surveyed will be collected. Providers will be asked a series of questions regarding their knowledge of, as well as attitudes toward, the new prescribing information for metformin issued by the FDA.RESULTS: Research in progress.CONCLUSION: Research in progress.Hematology/Oncology 10. COMPARISON OF TIME TO ABSOLUTE NEUTROPHIL COUNT RECOVERY IN PATIENTS WHO RECEIVED FILGRASTIM OR TBO-FILGRASTIM. Nan Patterson, Teresa Cooper, Jacyntha Sterling. Saint Francis Hospital, Tulsa, OklahomaINTRODUCTION: Febrile neutropenia (FN) is a serious side-effect of myelosuppressive chemotherapy treatment. Historically, filgrastim has been frequently prescribed by physicians to treat neutropenia in patients undergoing chemotherapy. Tbo-filgrastim is a competitor to filgrastim with a similar safety profile, but at a reduced cost. The objective of this study was to evaluate filgrastim and tbo-filgrastim for best prescribing patterns not relating to cost.METHODOLOGY: A retrospective chart review was performed on inpatient and outpatient subjects who have received at least one dose of filgrastim or tbo-filgrastim from January 1, 2015, to December 31, 2015. Subjects were identified using charge data for filgrastim or tbo-filgrastim. Patients were excluded from the study if they are stem cell donors, if they had unknown treatment history, or non-oncology neutropenia. Qualifying patients were divided in two groups: those who received filgrastim and those who received tbo-filgrastim. Eligible patients were randomized and placed into two arms of filgrastim or tbo-filgrastim with 100 patients in each arm. Each arm had a distribution of 75% inpatients and 25% outpatients. RESULTS: Overall, the differences between filgrastim and tbo-filgrastim were not clinically significant. The primary outcome of time to absolute neutrophil count (ANC) in both filgrastim and tbo-filgrastim groups were both 11 days. Inpatient lengths of stay between the groups were equal (15.8 days). Inpatient ANC at discharge for both groups were considered recovered (6.8 vs. 8.1). Incidence of FN was slightly increased in the tbo-filgrastim group (13% vs 10.6%). There was a 0.7% increase for confirmed infection in the filgrastim group which was not clinically significant.CONCLUSION: Overall results indicated that there was no significant difference in patient outcomes when comparing filgrastim to tbo-filgrastim. Pharmacy formularies can safely choose granulocyte colony-stimulating (GCSFs) on the basis of cost savings without compromising patient outcomes. Further study is necessary to investigate competitor GCSFs to determine ANC time of recovery.Infectious Diseases 11. EVALUATION OF THE USE OF DAPTOMYCIN PLUS CEFTAROLINE FOR THE TREATMENT OF MULTI-DRUG RESISTANT STAPHYLOCOCCAL AND ENTEROCOCCAL INFECTIONS. Amanda Bozell, Kari McCracken; St. John Medical Center; Tulsa, OKINTRODUCTION: In the setting of daptomycin-nonsusceptible vancomycin-resistant Staphylococcus aureus (VRSA), vancomycin-intermediate S. aureus (VISA), or vancomycin-resistant enterococci (VRE), limited data is available to support the use of alternative agents. Ceftaroline is a newer cephalosporin that has a broad spectrum of activity, which includes activity against methicillin-resistant S. aureus (MRSA), methicillin-sensitive S. aureus (MSSA), VISA, and VRSA. When used in combination, ceftaroline has been found to promote daptomycin binding to the cell membrane, therefore, increasing its efficacy. The primary outcome of this study is to determine the efficacy of daptomycin plus ceftaroline in treating resistant staphylococcal and enterococcal infections. Reported adverse events were recorded and identified as the secondary outcome. METHODOLOGY: Medication use data was collected to identify patients who received daptomycin plus ceftaroline from January 2015 through December 2016. Laboratory data was collected and analyzed to evaluate the efficacy of daptomycin plus ceftaroline in the treatment of multi-drug resistant staphylococcal and enterococcal infections during the same time period. Efficacy was determined by negative microbiological cultures, improvement in clinical response, laboratory values, and vital signs. Data that were collected and assessed include: patient's demographic information, length of hospital stay, laboratory values, antimicrobial use, length of antimicrobial therapy, organism(s) isolated, source of isolate, and susceptibility patterns. RESULTS: Results from this study will be used to support the clinical framework for determining an appropriate regimen for resistant staphylococcal and enterococcal infections. It is expected that the use of daptomycin plus ceftaroline will improve clinical outcomes in patients with multi-drug resistant staphylococcal and enterococcal infections.12. DAPTOMYCIN DOSING IN OBESE PATIENTS: ANALYSIS OF ADJUSTED BODY WEIGHT VERSUS ACTUAL BODY WEIGHT . Ashley N. Fox, Ryan E. Owens, Beth H. Resman-Targoff, Bryan P. White, Katherine Kupiec, Winter J. Smith. The University of Oklahoma College of Pharmacy, Oklahoma City, OKINTRODUCTION: FDA-approved daptomycin dosing is based on actual body weight (ABW), despite limited information regarding appropriate dosing for patients who are obese. Pharmacokinetic studies suggest daptomycin area under the concentration-time curve (AUC) is increased in obesity, while clearance and volume of distribution are reduced. Daptomycin use in obesity is associated with safety concerns, such as elevations in creatine phosphokinase (CPK) concentrations associated with increasing doses which may necessitate discontinuation of daptomycin therapy.The purpose of this study is to compare daptomycin clinical and safety outcomes in obese patients dosed by adjusted body weight (AdjBW) to a historical cohort dosed by ABW. METHODOLOGY: This retrospective study will evaluate daptomycin use in obese patients dosed on AdjBW (January 2014 – December 2015) versus a historical control (January 2012- December 2013) dosed using ABW. Inclusion criteria include: adult patients with a body mass index (BMI) of 30 kg/m2 or more who received daptomycin for at least 72 hours. Exclusion criteria are: daptomycin started prior to admission, infections with retained hardware, renal dysfunction, isolates not susceptible to daptomycin, or patients presenting with rhabdomyolysis. Demographics, concurrent medications, culture data, daptomycin indication, and daptomycin dose in mg/kg will be collected using a standard form. Safety data collected include baseline and serial CPK, patient-reported myopathy, and discontinuation of daptomycin due to adverse events. The primary outcome is clinical failure, defined as: development of resistance or recurrent signs and symptoms of infection necessitating antibiotic modification. Secondary outcomes include microbiologic success defined as at least one documented finding of microbiologic eradication and no evidence of subsequent clinical failure. A combined safety endpoint including elevation in CPK, patient-reported myalgia, and rhabdomyolysis requiring discontinuation of daptomycin will also be evaluated. Baseline characteristics will be evaluated using descriptive statistics. Multivariate logistic regression will be used to determine differences between cases and historical controls after adjusting for covariates in outcomes. Survival curves will be used to determine time to clinical success or failure.RESULTS: An interim analysis including patient demographics, clinical failure, microbiological success, and safety endpoints will be presented.CONCLUSION: Conclusions regarding daptomycin dosing for patients with obesity will be presented. 13. EVALUATION OF URINARY TRACT INFECTION (UTI) MANAGEMENT IN A COMMUNITY HOSPITAL WITH SUBSEQUENT PATHWAY DEVELOPMENT AND IMPLEMENTATION. Lauren May, Fran Esfahani, Brian Hughes, Norman Regional Health System, Norman, OK. PURPOSE: To evaluate current UTI-related practices, focusing on appropriate ordering, assessment, and treatment of urine cultures, with subsequent development and implementation of a UTI diagnosis and treatment pathway to decrease inappropriate urine culture ordering and streamline appropriate antibiotic treatment of true infection.METHODS: Phase one included an Investigational Review Board-approved randomized retrospective chart review of patients identified from a urine culture surveillance report dating from January to June 2016. Patients were excluded if pregnant, less than 18 years of age, or if there was insufficient information in the medical chart to evaluate appropriateness of therapy. Phase two includes development and implementation of a UTI diagnosis and treatment pathway. Subsequent data collection (phase 3) is to occur in late Spring 2017 in the same manner as phase one to determine improvement in appropriate urinalysis and antibiotic ordering after pathway implementation. RESULTS: Phase one analysis of 150 patients was performed. Of the patients identified, 16 met exclusion criteria. The location of urine sample collection was in the emergency department in 93 out of 134 patients. In 58% of patients, urine samples were collected for appropriate reasons (i.e. presence of any of the following: altered mental status, sepsis, urinary symptoms, signs of infection, or fall in elderly patients). Urine sample collection was deemed inappropriate in the remaining 42% of patients based on the absence of documented urinary symptoms with primary complaints of neurologic/psychologic, respiratory, cardiac, or abdominal symptoms or admission to inpatient rehabilitation unit. Urine cultures resulted with significant colony counts, no growth, contamination, or insignificant colony counts in 34%, 34%, 25%, and 7%, respectively. Appropriate treatment, whether that be giving or withholding antibiotic therapy, occurred in 91% of patients analyzed. Of the 21 patients identified as having asymptomatic bacteriuria, 38% were inappropriately treated with antibiotics. CONCLUSION: Analysis of phase one data suggests a significant number of urine samples gathered in the emergency department and on admission to inpatient rehabilitation unit are in patients without urinary symptoms documented; however, antibiotic selection for empiric treatment in those patients with suspected urinary tract infection was generally appropriate and consistent. Pathway development and removal of a default “urinalysis with reflex culture” order from many of the standard order sets may help to improve appropriate evaluation and subsequent treatment of urinary tract infections even further. 14. EVALUATION OF A PHARMACIST-LED VANCOMYCIN DOSING SERVICE IN THE MANAGEMENT OF OBESE VERSUS NON-OBESE PATIENTS. Molly Grasberger, Ann Lloyd, Vivian Carson, Jacyntha SterlingSaint Francis Hospital, Tulsa, OK INTRODUCTION: Vancomycin dosing in obesity is an area which lacks clear guidance due to altered pharmacokinetics versus non-obese. Pharmacist-led dosing protocols are associated with more patients being optimally dosed and less nephrotoxicity. The purpose of this study is to evaluate initial vancomycin trough concentrations for obese and non-obese patients dosed by the pharmacy vancomycin dosing service. Secondary outcomes include the number of supra- and subtherapeutic levels, number of follow-up consults and changes, and incidence of nephrotoxicity. A post hoc analysis was conducted to evaluate changes in dosing outcomes as a result of service changes implemented in 2013. METHODOLOGY: The electronic medical record was used to identify 188 patients admitted between January 1, 2015, and December 31, 2015, who received a minimum of 48 hours of intravenous vancomycin therapy and had ≥1 steady state trough obtained. Patients were excluded if they were receiving hemodialysis, pregnant, weighed <45 kg, age <18 years, received >1 dose of vancomycin outside of the pharmacy dosing service, or had no steady state trough. Data was collected on: demographics, vancomycin loading and maintenance doses, frequency, trough concentrations, follow-up consults, adherence to the dosing service, nephrotoxicity, concurrent nephrotoxic drugs, and comorbidities. Descriptive statistics were calculated to compare outcomes. RESULTS: Initial vancomycin trough concentrations were classified as therapeutic for 29 (30%) non-obese patients and 24 (26%) obese patients. 56 (58%) and 42 (46%) had initial trough concentrations that were sub-therapeutic, and 11 (11%) and 26 (28%) of non-obese and obese patients, respectively, had supra-therapeutic initial trough concentrations. 17 patients (10%) experienced nephrotoxicity at any point during vancomycin therapy. There were a total of 529 follow-up consults for all patients (average 3 per patient). There were a total of 62 and 53 subtherapeutic levels and 43 and 49 supratherapeutic levels for non-obese and obese patients, respectively. Overall clinical staff adherence to dosing service parameters was 36%. CONCLUSION: Patients were more likely to have a therapeutic or subtherapeutic initial trough, and less likely to have a supratherapeutic initial trough. It is unclear whether this correlates with changes made to the pharmacy dosing service given a high amount of variation in overall dosing service adherence.15. EVALUATION OF EMPIRIC APPROPRIATENESS OF DISCHARGE ANTIBIOTIC PRESCRIPTIONS FROM AN ACADEMIC MEDICAL CENTER EMERGENCY DEPARTMENT. Sara Kim, Shelton Knudsen, Kelly Murray, Aaron Lane. Oklahoma State University Medical Center, Tulsa, OKINTRODUCTION: Antimicrobial resistance is a growing problem that could be improved by implementing antibiotic stewardship activities into different practice settings. However, this has been a challenge for emergency departments (ED) due to the unclear diagnoses and the fast-paced environment. Pharmacists can have a significant impact with stewardship in EDs by aiding practitioners with empiric antibiotic selection and dosage. The objectives of this study are to evaluate the appropriateness of empiric antibiotic prescriptions written upon discharge for emergency department patients at an academic medical center and to describe medication errors found in the sample of antibiotic prescriptions. METHODOLOGY: This study has been approved by the OSU Center for Health Sciences Institutional Review Board. The study used content analysis to evaluate a random sample of 1000 empiric antibiotics that were submitted into the electronic medical record for discharged ED patients from July 1, 2015 to June 30, 2016. One clinical pharmacy resident and one ED medical resident reviewed the medication orders for errors following training in error identification, operational definitions, coding, and other information included in content analysis procedures. Open-ended data were coded and viewed by an ED clinical pharmacist for agreement on coding categories. Coding for the final data set was based on majority rule. The final data set was then evaluated based on age of patient, provider type, antibiotic prescribed, antibiotic and dosage selected, indication for antibiotic, type or description of error, and appropriateness of antibiotic selected. Clinical practice guidelines and institutional antibiograms were used to determine the appropriateness of empiric antibiotic selection. Descriptive statistics were used to address the study objectives. RESULTS: Discharge prescription error rate out of 500 prescriptions was 14.4%. Pediatric prescriptions comprised of 11.1% of the errors, and adult prescriptions comprised of 88.9% of the errors. The most common error type was due to dosing outside the recommended range. Prescriptions written with incorrect frequency schedules and durations of therapy comprised the majority of the errors. ED residents wrote the highest percentage of prescriptions (357), and had an error rate of 15.1%. The most prescription errors were made with the antibiotics nitrofurantoin, azithromycin, and penicillin. CONCLUSION: Discharge prescription errors are common in the emergency department setting. The most common errors seen were those that were dosed outside the recommended range. The researchers hope to further identify specific methods and implementations in which pharmacists can aid in decreasing the number and frequency of prescription errors. The researchers will continue to evaluate 500 additional prescriptions to identify any prescription error patterns that may exist.16. EVALUATION OF FIDAXOMICIN USAGE PATTERNS AND NAP1 PREVALENCE IN CLOSTRIDIUM DIFFICILE INFECTION ACROSS THE VETERANS HEALTH ADMINISTRATION. Stephanie E. Giancola, Riley Williams II, Sharanjeet Thind, George Kurdgelashvili, Grant H. Skrepnek, Chris A. Gentry. Oklahoma City VA Health Care System, Oklahoma City, OKINTRODUCTION: The epidemic shift in Clostridium difficile infections (CDI) that occurred in the early 2000s is partly attributed to the emergence of the North American pulsed-field gel electrophoresis type 1 (NAP1) strain. The NAP1 strain is highly virulent, causing higher recurrence of CDI, morbidity, and mortality. These factors have led to calls for improved therapeutic options. Fidaxomicin, approved by the FDA in 2011, is a highly-potent antimicrobial agent against C. difficile. The purposes of this study are to assess trends in NAP1 prevalence across the Veterans Health Administration (VHA) system, to describe patient characteristics and outcomes following fidaxomicin treatment in the VHA system, and to assess compliance with VHA fidaxomicin criteria for use. METHODOLOGY: A retrospective, observational, nationwide study of patients with CDI at any Veterans Affairs Medical Center (VAMC) found to routinely test for presence of NAP1 between July 1, 2011 and June 30, 2016 will be conducted. Trends will be described by timeframe, geographic regions, and facility complexity level. All patients treated with fidaxomicin for CDI at any VAMC between June 1, 2011 and October 31, 2016 will be identified. The primary endpoint will be compliance with the fidaxomicin criteria for use. Alternative uses outside of criteria for use guidance will be described. Descriptions of usage trends will include sub-analyses by geographic regions, timeframe, facility complexity level, and presence of NAP1. Secondary outcomes for patients who received at least 72 hours of fidaxomicin will include outcomes of clinical failure and/or CDI recurrence, hospital length of stay where applicable, and 30-day all-cause mortality. RESULTS: Routine testing for NAP1 was found for 32 VAMC’s. The prevalence of C. difficile strains exhibiting presence of NAP1 was 21.9% (1802/8224). One thousand ninety-nine patients received at least one dose of fidaxomicin during the study period, including 620 inpatient courses. The characteristics of patients and their courses of fidaxomicin will be described, as well as the trends in NAP1 prevalence.CONCLUSION: NAP1 prevalence and fidaxomicin usage patterns across nationwide VAMC’s will be characterized.17. ASSESSMENT OF ANTIRETROVIRAL USE AT AN ACADEMIC MEDICAL CENTER. Adre Cullen, Connel Christina, Bury John; Oklahoma State University Medical Center, Tulsa, OKINTRODUCTION: HIV is a disease where outcomes are determined by medication therapy and pharmacists play an integral role in the multidisciplinary management. As the population of patients with HIV grows, there is an increased need for monitoring of significant drug interactions and ensuring appropriateness of antiretroviral therapy upon initiation and maintenance in the inpatient setting. Therefore, the purpose of this study is to assess the use of antiretrovirals in an inpatient academic medical center, specifically determining errors that occur in a sample of antiretroviral regimens. METHODOLOGY: The electronic medical record system was used to identify patients who had been prescribed antiretrovirals in the inpatient setting. The following data was collected: sex, age, weight, height, serum creatinine, antiretroviral allergies, antiretroviral(s) selected, admitting team/hospitalist group, inpatient medication list and home medication list. Each profile was assessed for appropriateness of antiretroviral regimens prescribed and potential interactions.RESULTS: A total of 138 patient encounters were evaluated to date. Results from these encounters show 78.2% of HIV encounters were handled appropriately, 13% of encounters resulted in some form of an error, 7.97% of encounters had a potential for error, and 0.95% of encounters fell in the other category. Of those handled appropriately, 31.8% received the correct antiretroviral therapy and 46.3% did not receive antiretroviral therapy. Errors were divided into 3 categories: inappropriate doses (5.7%), incomplete regimens (5.7%), and significant drug interactions (1.44%). The encounters with a potential for error included patients whose prescriptions may have been timed inappropriately. CONCLUSION: Pharmacists play an important role in antiretroviral stewardship to identify significant drug interactions and ensure optimal antiretroviral therapy. Despite 78.2% of patient encounters being handled appropriately, 13% of encounters resulted in an error. Implementation of a pharmacist led antiretroviral stewardship program could help alleviate errors including: inappropriate doses, incomplete regimens and drug interactions. More research is needed to finalize these results and determine the best way to implement a novel antiretroviral stewardship program in an academic setting. 18. CLINICAL OUTCOMES OF SINGLE TABLET VS. MULTI-TABLET ANTIRETROVIRAL REGIMENS IN HIV-INFECTED INDIVIDUALS. Jeannie Ong, Michelle D. Liedtke, R. Chris Rathbun, and Grant H. Skrepnek. University of Oklahoma College of Pharmacy, Oklahoma City, OKINTRODUCTION: Highly active antiretroviral therapy (HAART) reduces disease progression in individuals infected with the human immunodeficiency virus (HIV) and reduces associated morbidity and mortality. Since the FDA-approval of Atripla in 2006, single tablet regimens (STR) have been associated with improved medication adherence, virologic suppression, higher patient satisfaction, fewer hospitalizations, and reducing healthcare costs. Five additional STR have been FDA-approved in the past 5 years; however, data are presently lacking on the comparative effectiveness of these STR vs. other ART. This study will examine clinical outcomes with newer STR formulations compared with traditional multi-tablet regimens to determine whether benefits are realized.METHODOLOGY: This study will be retrospective, observational study of existing HIV-infected patients at the OU Infectious Disease Institute (IDI) clinic located on the OU Health Sciences Center campus in Oklahoma City, OK between 2011 and 2016. Adult, HIV-infected individuals managed by the OU Infectious Disease Institute clinic who received antiretroviral therapy will be eligible for inclusion in the study. Eligible patients will be identified by medical provider utilizing the OU Pharmacists Care Center (OUPCC) claims data. HIV-seropositive patients on antiretroviral therapy will be identified using prescribing provider from the IDI clinic and a generic product identifier. Claims data will be collected from OUPCC. Medication possession ratio will be calculated to analyze refill claims data to assess patient adherence to antiretroviral therapy. Demographic (e.g. age, race, sex, HIV risk category, HIV treatment na?ve or experienced) and disease parameters (e.g. baseline CD4 cell count, plasma HIV RNA, date of HIV diagnosis, co-morbidities) will also be collected from electronic medical records to examine associations with the various clinical outcomes.RESULTS: In progress.CONCLUSION: It is our expectation that patients receiving STR will demonstrate improved clinical outcomes such as superior medication adherence and will achieve higher rates of virologic suppression. As a result of this study, the outcome of this investigation will inform clinicians on the relative benefits of STR versus MTR when selecting antiretroviral therapy.19. DETERMINATION OF MEDICATION POSSESSION RATIO ACCORDING TO ANTIRETROVIRAL CLASS. Krista Williams, Michelle D. Liedtke, R. Chris Rathbun, Grant Skrepnek. University of Oklahoma. Oklahoma City, OKINTRODUCTION: The use of highly active antiretroviral therapy (HAART) revolutionized the management of the human immunodeficiency virus. It is essential to be able to monitor patient adherence; although, no gold standard exists to measure adherence to antiretroviral therapy in clinical practice. Medication possession ration (MPR) is a readily available mechanism to measure adherence and offers a more objective method than patient self-report. METHODOLOGY: The objective of this retrospective observational study is to examine the relationship between adherence and viral suppression and to determine the Medication Possession Ratio (MPR) required to achieve viral load suppression according to medication class. Approximately 1600 patient records from January 1, 2015 to December 31, 2016 will be evaluated for inclusion in this study. Eligibility criteria include HIV-seropositive patients on HAART who receive care at the Infectious Disease Institute Clinic, receiving medications from the OU Pharmacist Care Center and have at least 4 viral load during the study period. Exclusion criteria include: pregnancy, less than 4 viral loads, imprisonment, use of pharmacies other than OUPCC, and on ART less than 6 months. Viral loads will be collected from the electronic medical record for patients who meet inclusion criteria. Next, MPRs will be calculated for the patients. Medication Possession Ratio will be calculated using the following formula: MPR= Number of days'supply of Antiretorival dispensedNumber of days in the interval where the number of days’ supply in the interval will reflect the number of days between the first fill date for antiretroviral therapy and the end of the study period (designated as December 31, 2016). MPR values will be expressed as percentages.RESULTS: In progressCONCLUSION: Pending results20. IMPACT OF A CHANGE IN SERVICE ON SUSTAINED VIROLOGICAL RESPONSE RATES IN VETERANS RECEIVING LEDIPASVIR/SOFOSBUVIR FOR MANAGEMENT OF HEPATITIS C. Scott Mirgeler, Riley Williams II, Jennifer Bird, Rona Furrh. Oklahoma City VA Healthcare System, Oklahoma City, OKINTRODUCTION: The Veterans Health Administration (VHA) is the single largest provider for the treatment and management of Hepatitis C Virus (HCV) in the United States. With the introduction of new and highly effective direct-acting antivirals, there is potential to cure HCV infection and reduce the risk of complications such as cirrhosis and hepatocellular carcinoma in the Veteran population. In May 2016, the Oklahoma City VA expanded its HCV treatment workforce capacity by engaging clinical pharmacy specialists and primary care physicians to aid in the management of non-complicated HCV cases. Previously, Veterans with HCV infection received all HCV-related care within the Gastroenterology (GE) Department. Since the change in service, GE still receives all HCV referrals, conducts the initial patient work-up and evaluation, and selects the treatment regimen. Complicated cases, defined as a Veteran with cirrhosis and/or requiring ribavirin-containing regimens, are retained under care of the GE Department. Uncomplicated cases are referred to a clinical pharmacy specialist who verifies and initiates the treatment regimen, provides education and counseling to the Veteran, and then facilitates transition of care and treatment monitoring follow-up to the Veteran’s Primary Care Physician. This study aims to determine if these changes have had any impact on sustained virologic response (SVR) and compliance rates of Veterans treated for uncomplicated cases of HCV infection. Furthermore, the data and results of this study will help reveal patient-specific and systematic factors that may contribute to HCV treatment failure and non-compliance. This site-specific data can be utilized to evaluate the effectiveness of the new service model and identify areas of improvement for the treatment and management of Veterans with HCV.METHODOLOGY: The study is an institutional review board-approved, retrospective, descriptive chart review. Adult Veterans aged 21 years and older with HCV infection who received a prescription for ledipasvir/sofosbuvir between January 2015 through October 2016 from either GE or Clinical Pharmacy were included in the study. Veterans were excluded if they had biochemical signs of cirrhosis and/or received ribavirin-containing HCV regimens. Data collection includes Veteran demographics, past medical history, social history, labs, imaging, medication history, and hepatitis treatment and follow-up course per provider documentation. The primary outcome of the study is to determine differences in SVR between Veterans receiving treatment with ledipasvir/sofosbuvir for uncomplicated HCV infection under the care of GE compared to Clinical Pharmacy/Primary Care. Secondary outcomes include differences in HCV medication and treatment monitoring follow-up compliance rates between the two groups, and determination of variables that may contribute to non-compliance. Statistical analysis will utilize the Chi-squared test for the primary outcome and for categorical variables, and a t-test to compare calculated means and standard deviations from all continuous and descriptive independent variables. All statistical tests will be conducted with a priori alpha level of 0.05 utilizing statistical software.RESULTS: data collection in progressCONCLUSION: pending results 21. DETERMINATION OF MEDICATION POSSESSION RATIO FOR VIRAL SUPPRESSION IN HIV-INFECTED ANTIRETROVIRAL-NA?VE PATIENTS. Marcus Tad Autry, Chris Rathbun, Michelle Liedtke, Grant Skrepnek, and Jamie MillerThe University of Oklahoma College of Pharmacy, Oklahoma City, OklahomaINTRODUCTION: The advent of newer and safer fixed-dose combination antiretrovirals (ARV) has made the treatment of HIV simpler and more convenient from a patient perspective. However, the failure of these regimens due to non-adherence and the development of resistance has the potential to eliminate more tolerable ARV regimens as treatment options. Determining adherence thresholds that predict a high likelihood for chronic viral suppression is important for the chronic management of HIV infection. Furthermore, determination of adherence thresholds for the three primary regimen types (non-nucleoside reverse transcriptase, protease, and integrase inhibitor) that are associated with viral suppression would allow practitioners to make more informed treatment decisions based upon adherence measures before the appearance of breakthrough viremia, thereby decreasing the risk of developing resistance. Previous research has established adherence thresholds that are associated with virologic suppression; however, this research included treatment-experienced individuals whose prior use of ARV could affect adherence, and thus the threshold, needed for suppression. The adherence thresholds for the three primary regimen types are currently undefined in the treatment-na?ve population.METHODOLOGY: A retrospective observational cohort study will be conducted of HIV-infected patients greater than 18 years of age at a university affiliated outpatient infectious diseases clinic. Treatment-na?ve individuals who have received antiretroviral therapy at the OU Health Sciences Center Infectious Diseases Institute for at least one year between January 2011 and December 2016 will be identified. Antiretroviral claims data for medication possession ratio (MPR) determination will be obtained from the designated drug assistance program pharmacy. Real-time PCR HIV-1 RNA, CD4, and demographic data will be collected from electronic medical records. Composite MPR will be calculated for the full antiretroviral (ARV) regimen. Viral load area-under-the curve (vAUC) will be quantified using WinNonLin pharmacokinetic software to assess continuous viral suppression over the study period. Regression will be used to examine existing relationships between refill adherence rates and different levels of HIV viremia and will be offset for the overall duration of patient follow-up and controlled for age, sex, race/ethnicity, antiretroviral regimen type, and MPR. A marginal effects analysis will be used to determine the predicted probability of viral suppression (defined as HIV-1 RNA < 50 copies/mL) and MPR. Analysis will be stratified by antiretroviral regimen class to determine whether differences in specific thresholds exist. RESULTS: Interim analysis regarding patient demographic and clinic care-related data will be presented. CONCLUSION: Conclusions regarding study findings to date will be presented. Pediatrics 22. COMPARISON OF AMIKACIN PHARMACOKINETICS IN NEONATES WITH AND WITHOUT CONGENITAL HEART DISEASE. Amy Nguyen, Peter Johnson, Katie Hughes, Michael Anderson, Kris Sekar, Robert Welliver, Jamie Miller. University of Oklahoma College of Pharmacy, Oklahoma City, OKINTRODUCTION: Aminoglycosides are commonly used in the neonatal ICU (NICU) in combination with other antibiotics for treatment of early and late onset sepsis. Although gentamicin or tobramycin are often first-line, the use of amikacin has escalated in certain facilities due to observed antimicrobial resistance patterns. However, there is a paucity of data in the neonatal population, especially in neonates with congenital heart disease (CHD). The purpose was to compare amikacin pharmacokinetics and acute kidney injury (AKI) in neonates and infants with and without CHD.METHODS: This was a descriptive, retrospective study of neonates and infants who received amikacin from January 1, 2013 through December 31, 2016. Infants with CHD defects were classified as cyanotic or acyanotic. Non-CHD controls were matched in a 2:1 fashion according to postmenstrual age (PMA). The primary objective was to compare the volume of distribution (Vd) and clearance (CL) of amikacin in neonates with CHD versus controls. Secondary objectives included comparisons of elimination rate (Ke) and half-life (t1/2). In addition, the incidence of AKI was compared between groups. AKI was defined as a reduction in urine output to <0.5 mL/kg/hr > 8 hours, an absolute increase in serum creatinine (SCr) by 0.3 mg/dL, or an increase in SCr greater than 50% from baseline. Between-group analyses will be performed using Wilcoxon-Mann-Whitney test, Student’s t-test or Chi-square, or Fisher’s exact analysis as appropriate with a p-value < 0.05.RESULTS: Seventy-one CHD patients met inclusion criteria and were matched to 142 control patients. To date, data collection has been completed only for the CHD patients. The mean weight was 2.83 ± 1.18 kg. The mean amikacin dose utilized was 13 ± 1.66 mg/kg and duration of therapy was 6.0 ± 3.0 days. The mean Vd and CL were 0.48 ± 0.11 L/kg and 0.05 ± 0.01 L/kg/hr, respectively. The mean Ke and t1/2 were 0.11 ± 0.03 hrs-1 and 6.79 ± 2.15 hours, respectively. Fifteen infants (21.7%) met the criteria for AKI.CONCLUSIONS: Final conclusions will be presented23. PEDIATRIC DELIRIUM EDUCATION: DETERMINING THE EFFICACY OF EDUCATING PEDIATRIC STAFF ON DELIRIUM AND SCREENING TOOL UTILIZATION PRIOR TO PROTOCOL IMPLEMENTATION. Allyson D. Gabbard, Leslie Patatanian, INTEGRIS Baptist Medical Center, Oklahoma City, OK.INTRODUCTION: Pediatric delirium has received increasing attention over the past 15 years and has been associated with outcomes including increased morbidity, mortality, hospital stay duration, and healthcare costs. Several pediatric delirium screening tools have been developed and validated, but approximately 71% of healthcare facilities with a pediatric intensive care unit (PICU) don’t regularly screen their patients. Roughly 2% evaluate all patients every shift as recommended. Significant knowledge gaps exist with regards to pediatric delirium, and want of effective education may be partially at fault for the lack of action being taken. The purpose of this study is to evaluate the efficacy of education modules in preparing pediatric staff for implementation of a pediatric delirium screening protocol. Development of effective education will remove barriers preventing healthcare facilities from addressing this condition thus allowing the focus to shift from education to prevention and treatment.METHODOLOGY: After completion of a study consent form, subjects began phase I of the study comprising a 21-question assessment administered before and after finishing a general education module on pediatric delirium. After completion of these steps, subjects proceeded to phase II comprising an education module detailing proper utilization of the Cornell Assessment of Pediatric Delirium (CAPD) followed by a 14-question post-assessment. Subjects completed these steps at their convenience through the use of provided instructions documents. Assessments were made available through the online service SurveyMonkey?. Education modules were made available online as invisible YouTube? videos.RESULTS: Preliminary: Forty-seven subjects signed informed consent forms, and 30 subjects within the nursing and pharmacy professions have initiated the study. All 30 subjects completed the phase I pre-assessment yielding an average score of 46%, approximately 10 questions answered correctly out of 21 questions. Seventeen subjects completed the phase I post-assessment yielding an average score of approximately 77%, 16 questions out of 21 questions answered correctly. This shows the phase I education module enabled subjects to answer 6 more questions correctly on the phase I post-assessment thus improving their phase I pre-assessment scores by 31%. Nine subjects completed the phase II post assessment, and none had prior education on utilization of the CAPD. These subjects produced an average score of 88% equaling approximately 12 out of 14 questions answered correctly.CONCLUSION: Based on this preliminary data, pediatric delirium education modules are effective at improving pharmacist and nurse knowledge on pediatric delirium.24. IMPLEMENTATION OF STRATEGIES TO REDUCE ALERT FATIGUE ASSOCIATED WITH ELECTRONIC ORDER ENTRY IN A CHILDREN’S HOSPITAL. Christine Hughes, Bob M. John, Marlene V. Hall, David V. Donald, Jacyntha Sterling. Children’s Hospital at Saint Francis, Tulsa, OKINTRODUCTION: Electronic Health Record (EHR) systems allow for improved patient safety, improved treatment outcome, and streamlined processes. However, the high frequency of notification alerts during order entry in an EHR results in alert fatigue. With alert fatigue, alerts are so common that the end user ceases to pay attention to them and so may overlook a critical alert, which could influence patient safety and treatment outcome. This study aims to better understand patterns of alerts and overrides in order to identify system and education opportunities that improve safety and enhance the ordering system process for the Children’s Hospital.The primary goal of this study is to reduce the number of medication alerts that could lead to alert fatigue by improving alert quality without negatively impacting patient health and safety. Evaluation and analysis of alerts will drive system and/or education changes to ensure that the most frequent alerts are more meaningful to the end user. The secondary goal is to gauge perception of medication alert quality and quantity by ordering providers.METHODS: The goals will be achieved by reviewing alerts from data extracted from medication alert system reports from the institution’s EHR with a team comprised of clinical pharmacists and the information technology (IT) EHR specialist. A provider survey will also be conducted before and after implementation to evaluate differences in perceptions of the quality and quantity of the alerts.The results of this study should include a process by which alert notifications can be regularly monitored and managed for maximum safety and efficacy.RESULTS: Not yet availableCONCLUSION: Not yet available25. CYSTIC FIBROSIS PATIENT EDUCATION – IS THE CF CENTER MEETING PATIENT AND FAMILY NEEDS? Kevin Lonabaugh, Katherine O’Neal, Heather McIntosh, Michelle Condren. University of Oklahoma College of Pharmacy; Tulsa, OKINTRODUCTION: Cystic fibrosis (CF) is a complex chronic disease state involving multiple organ systems. Medication regimens include numerous therapies and utilize various routes of administration. Patients and their families require education about the role of these medications as well as how to use them. In addition, patients are expected to receive information regarding the disease state itself and considerations for daily living with CF. Current guidelines have identified educational goals from birth through pre-school, however the timing for providing that education is not explicitly described past the pre-school age. Prior research has highlighted knowledge gaps amongst patients with CF, especially in areas related to genetics and reproduction. Studies have also suggested that patient knowledge is associated with increased adherence and that medical professionals are an important educational source. It is therefore critical that CF centers create a systematic means of providing patient and family education. Clinical research has yet to evaluate patient perceptions of the education they have been provided as well as when they would like that education to occur. The purpose of this study is to improve the quality of patient education in the clinic by evaluating patient perceptions of education provided there as well as their own self-confidence related to particular topics within CF. The study will assess how well their self-confidence matched their knowledge about CF topics and will define patient-specific goals for timing of education and sources of information.METHODOLOGY: This prospective study recruited patients and caregivers at a single accredited Cystic Fibrosis Foundation center from January 2017 through April 2017. Patients and their caregivers were included upon presentation for a normal care visit. Patients were excluded if their primary language was a language other than English, if they had a history of lung transplantation, or if they had a diagnosis of CF-related metabolic syndrome (CFMS). The questionnaires were developed by experts in CF and piloted before distribution. Five versions of the questionnaire were developed for the different respondents (adolescent patient, adult patient, child caregiver, adolescent caregiver, and adult caregiver). The questionnaires had 72-77 items divided into five sections related to 1) patient opinions regarding clinic provision of education, 2) confidence regarding their knowledge, 3) questions related to age-appropriate education, 4) questions related to their usual sources of information, and 5) a knowledge assessment using a validated scale for that age group. This study has been approved by the University of Oklahoma Institutional Review Board.RESULTS: This research project is currently in progress.26. PHARMACOKINETIC SIMULATIONS OF FENTANYL CONTINUOUS INFUSIONS IN NON-OBESE VERSUS OBESE CHILDREN. Sin Yin Lim1; Sukyung Woo1; Jamie L. Miller1-2; Grant H. Skrepnek1; Henry D. Emily2, Peter N. Johnson1-2. University of Oklahoma Colleges of Pharmacy1 and Medicine2; Oklahoma City, OKINTRODUCTION: A paucity of studies have evaluated the pharmacokinetics (PK) of medications in obese children. The objective was to compare fentanyl continuous infusion PK between obese (OC) and non-obese children (NC).METHODOLOGY: This PK simulation study utilized a semi-physiologic approach to evaluate fentanyl PK using historical inpatient data in <18 year-olds admitted in 2011. OC was defined as children < 2 years with weight-for-length >97.7th percentile or BMI-for-age >95th percentile for >2-17 year-olds. The primary objective was to compare the total clearance (CL) and steady state volume of distribution values (Vss) based on obesity status in different age groups (0 to <2, 2, 6, 10, 14, and 17 years). The secondary objective was to compare fentanyl plasma concentration-time profiles simulated for three OC and three NC ages 4, 9, and 15 years, based on weight-adjusted does of 1 mcg/kg/hr using total body weight. An additional simulation was conducted for 15 year OC and NC using a fixed dose of 50 mcg/hr. Simulations were performed using Berkley Madonna software. A multivariable regression analyses was conducted to determine the association of Vss and CL with obesity, females, and age. Data analysis was conducted using a Student’s t test with a p-value <0.05.RESULTS: Historical data included 4376 patients, with 807 (18.4%) classified as OC. The majority (52.9%) were male with a median age of 8.1 years [interquartile range (IQR) 4.3-13.0]. There was an 11-30% decrease in weight-normalized total CL in OC versus NC in all groups. However, statistically significant differences were only found in 6, 10, 14, and 17 year-olds, p<0.05. Controlling for sex and age, the Vss were two to five times higher in OC. Weight-normalized Vss values also increased more than two-fold in OC compared to NC. In early drug disposition (<24 hours) for the simulated OC and NC 4, 9, and 15 year-olds, weight-adjusted doses resulted in similar concentrations between groups. However, after >24 hours, weight-adjusted dosing in OC resulted in higher concentrations than NC. Steady-state concentrations using weight-based dosing increased by 25%, 77%, and 44% in OC versus NC 4, 9, and 15 year-olds respectively. Time to steady-state and elimination half-lives were two to four-fold longer in OC. Fixed dose (mcg/hr) provided similar PK profiles in OC and NC 15 year-olds.CONCLUSION: Weight-normalized total CL was lower in OC in all ages. Weight-normalized Vss values were higher in OC versus NC. The PK effect of obesity resulted in a significant increase in steady-state concentrations in 4, 9 and 15 year-old OC. Exploring alternative dosing strategies is warranted for OC. ................
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